Fibromyalgia

K. Mukhida Department of Anesthesiology, Pain Management and Perioperative MedicineDalhousie UniversityFebruary 2019

Disclosures• None

ObjectivesAt the end of this session you will be able to:

• Assess a patient with CWP and know the diagnostic criteria for fibromyalgia

• Come up with a differential diagnosis for CWP

• Come up with management options for the patient with fibromyalgia

• Nociceptive: damage (trauma, inflammation)

• Neuropathic: nerves

• Centralized: neuronal dysregulation, overactive pain pathways,deficiency of descending inhibitory pain pathways

Hauser W and Fitzcharles M-A (2018). Dialogues Clin Neurosci 20: 53-61.Atzeni F et al. (2017). Expert Opinion on Emerging Drugs 22: 357-367.

CL is a 56 year old woman who is new to your practice.

She tells you that she is coming to see you because shehas pain “all over.”

History

PMH

FMH

Social

Physical examination

Investigations

Arnold LM et al. (2018). The Journal of Pain https://doi.org/10.1016/j.pain.2018.10.008.

PAIN

FATIGUE

SLEEP DISTURBANCES

COGNITIVE PROBLEMS

Clauw DJ (2014). JAMA 311: 1547-1555.

• Widespread pain index: at least 7

AND

Symptom severity score: at least 5

OR WPI 4-6 AND SSS over 9

• Diagnosis is valid irrespective of other diagnoses

Wolfe F et al. (2016). Seminars in Arthritis and Rheumatism 46: 319-329.

What is in your differential diagnosis for CL’s pain?

Inflammatory rheumatic diseases

Nonrheumatic msk conditions

Nonrheumatic medical conditions

Neurological conditions

Mental health disorders

Medication-induced pain conditions

Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases

Symptoms: joint swelling

Examples: SLE, RA, Sjogren, scleroderma, inflammatory polyarthritis, PMR, inflammatory spondyloarthritis

Red flags: FHx, am stiffness > 1 hr, severe constitutional symptoms

Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases

Nonrheumatic msk conditions

Symptoms: trigger points

Examples: myofascial pain syndrome, CTDs

Red flags: pronounced neck and shoulders

Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases

Nonrheumatic msk conditions

Nonrheumatic medical conditions

Endocrine / metabolic: hypothyroidism, hyperparathyroidism, acromegaly

GI: celiac disease

ID: Lyme disease, hepatitis C, HIV

Hauser W et al. (2018). Pain Reports e958.

Inflammatory rheumatic diseases

Nonrheumatic msk conditions

Nonrheumatic medical conditions

Neurological conditions

Examples: MS, PD, peripheral neuropathies, myelopathy, myopathies

Hauser W et al. (2018). Pain Reports e958.

Medication-induced pain conditions

Statins

Opioids

Chemotherapy

Aromatase inhibitors

bisphosphonates

Hauser W et al. (2018). Pain Reports e958.

P

P

P

P

Physical

PsychologicalPins

Pharmacological

*

• Exercise

• Meditative movement therapies

• Dance

Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.Bidonde J et al. (2017). Cochrane Database of Systematic Reviews 6: CD012700.

Gota CE (2018). Cleveland Clinic Journal of Medicine 85: 367-376. Honda Y et al. (2018). Pain Research & Management https://doi.org/10.1155/2018/2930632.

Murillo-García et al. (2018). Evidence-based Complementary and Alternative Medicine 8709748.Sosa-Reina MD et al. (2017). BioMed Research International 2356346.

Sawynok J & Lynch M (2017). Medicines 4: 37.

Overview of recommended treatment strategies:

Pharmacological managementLevel of evidence Strength of recommendation

Amitriptyline 1 (weak for) AAnticonvulsants 1 (weak for) AMuscle relaxant - -SNRIs 1 (weak for) ASSRIs 1 (weak for) Amulticomponent therapy 5 D

Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.Fitzcharles MA et al. (2012). Pain Research and Management 18: 119-126.

Macfarlane GJ et al. (2017). Annals of Rheumatologic Disease 76: 318-328.

• Not responsive to injections

• CBT

Aman MM et al. (2018). Current Pain and Headache Reports 22: 33. Bernardy K et al. (2017). European Journal of Pain 22: 242-260.

Bernardy K et al. (2018). European Journal of Pain doi: 10.1002/ejp.1284. Mehta S et al. (2018). Journal of Behavioral Medicine https://doi.org/10/1007/s10865-018-9984-x

Overview of recommended treatment strategies:

Nonpharmacological managementLevel of evidence Strength of recommendation

Aerobic exercise 1 (strong for) ABalneotherapy - -Cognitive behavioural therapy 1 (weak for) A Defined physical therapies 1 (weak for) AMeditative movement therapies 1 (weak for) AMindfulness-based stress reduction - -Strengthening exercise 1 (strong for) A

Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.Fitzcharles MA et al. (2012). Pain Research and Management 18: 119-126.

Macfarlane GJ et al. (2017). Annals of Rheumatologic Disease 76: 318-328.

Confirm diagnosis:- ID important symptom domains / level of function- Evaluate for comorbid medical / psychiatric disorders- Assess psychosocial stressors, level of fitness, barriers to treatment- Provide education about FM

Recommend individualized treatment

Nonpharmacological therapy:- CBT - Exercise

Pharmacological therapy:

Depression- SNRI

Sleep- ⍺2d ligand

Partial response monotherapy- ⍺2d ligand +/- SNRI +/- TCA

Arnold LM & Clauw DJ (2017). Postgraduate Medicine 129: 709-714.